MedStar Safety Science report from the National Academies

By: guest blogger Dr. Rollin J "Terry" Fairbanks*  

As many of us are digging out of a week of snow and cold temperatures, it’s hard to believe that it was June when the MedStar Health Research Institute and the National Academies' University Industry Demonstration Partnership (UIDP) hosted a “Resilience in Healthcare” workshop at the National Academies.  Neil’s devoted blog followers might recall his post on this conference and how the healthcare industry is interested in applying the rules of resilience engineering to improve patient safety: 

The conference attracted more than 100 experts from leading institutions around the Nation, and as the program director for the conference I can tell you that the energy, excitement and knowledge exchange around this emerging field of research was truly inspiring. 

This month, the National Academies released a final report on the conference, and the PDF is available using this link.. In this report, the conference is summarized with key findings such as the difference between two fundamental interpretations of safety: safety-I and safety II. Safety-I is defined by the absence of things that can lead to a negative outcome, such as hazards, accidents, incidents, and near misses, while safety-II is defined by the ability  to succeed in both expected and unexpected situations:

The conference also included several case presentations with expert panel discussion to offer a resilience engineering perspective. Seth Krevat, assistant vice president for safety at MedStar Health, presented the first case, involving a medication error that resulted in a chemotherapy patient receiving both the wrong drug and the wrong dose.  Paul Plsek, an expert in complexity theory from the MedStar Institute for Innovation, served as the facilitator for the meeting, and many members of the advisory board for MedStar Health’s National Center for Human Factors in Healthcare served as speakers. 

It was a privilege for MedStar Health to co-host to such a groundbreaking meeting and I encourage anyone who did not attend the workshop and has interest in this emerging field to read the report.

*About the author:   Rollin J “Terry” Fairbanks Director of the National Center for Human Factors in Healthcare and of the Simulation Training & Education Lab (SiTEL) at MedStar Health, and Associate Professor of Emergency Medicine | Georgetown University. He is a human factors/safety engineer and emergency physician. He can be followed on twitter @TerryFairbanks